Behavioral Health Care Management Program



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Administration of Behavioral Health Programs


Blue Cross and Blue Shield of Texas (BCBSTX) administers behavioral health services (mental health and substance use disorder) for members who have behavioral health benefits through a variety of retail, government and group products including Blue Choice PPOSM and Federal Employee Program® (FEP®) members.


Program changes for some provider networks

  • As of June 1, 2020, BCBSTX will manage behavioral health benefits for Blue EssentialsSM, Blue Essentials AccessSM, Blue PremierSM and Blue Premier AccessSM.
  • As of Sept. 1, 2020, BCBSTX will manage behavioral health benefits for HealthSelect of Texas® and Consumer Directed HealthSelectSM (HealthSelect). Refer to ERS Tools for more details.

Refer to the Behavioral Health Changes FAQs .


Magellan Healthcare® (Magellan) administers behavioral health services for members enrolled in:

  • Blue Advantage HMOSM, Blue Advantage PlusSM HMO
  • MyBlue HealthSM
  • Blue Cross Medicare Advantage HMOSM
  • Medicaid STAR, CHIP and STAR Kids.

In addition, some groups may select other vendors to administer their behavioral health services. For that reason, it is imperative to use Availity® or your preferred vendor to obtain eligibility and benefits, determine who is responsible for administering behavioral health benefits and prior authorization requirements.


Behavioral Health Program Overview


BCBSTX’s behavioral health care management is integrated with our medical care management program, to help members access their behavioral health benefits and to improve coordination of care between medical and behavioral health providers. This program will help our clinical staff identify members who could benefit from co-management earlier and may result in:

  • Improved outcomes
  • Enhanced continuity of care
  • Greater clinical efficiencies
  • Reduced costs over time

Some members* may be referred to other medical care management programs that are designed to help identify and help close potential gaps in care through evidence-based and member-focused approaches to health care and benefit decisions.


All behavioral health benefits are subject to the terms and conditions as listed in the member's benefit plan.


* Members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications may be referred to medical care management programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals and physician referrals. If members do not have medical care management programs as part of their group health plans, they will not be referred to other medical care management programs.


Availity is a trademark of Availity, L.L.C., a separate ‭company that operates a health information network to ‭provide electronic information exchange services to ‭medical professionals. Availity provides administrative ‭services to BCBS‬‬‬‬TX. BCBSTX makes no endorsement, ‭representations or warranties regarding any products or ‭services offered by independent third-party vendors such ‭as Availity. If you have any questions about the products ‭or services offered by such vendors, you should contact ‭the vendor(s) directly.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬




Health Care Service Corporation, Inc. (operating through its five divisions: BCBS of Illinois, BCBS of Montana, BCBS of New Mexico, BCBS of Oklahoma, and BCBS of Texas) Behavioral Health Care Management program has been accredited for Health Utilization Management since October of 2012. This accreditation covers the Behavioral Health Utilization Management program for Commercial/Group, FEP and Retail Exchange Affected Markets lines of business for all five plan states.

 

URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC strives to ensure that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. For more information, visit www.urac.org.


The BCBSTX Behavioral Health Program encompasses a portfolio of resources that help BCBSTX members access benefits for behavioral health (mental health and substance use disorder) conditions as part of an overall care management program. It also allows our clinical staff to assist in the early identification of members who could benefit from co-management of behavioral health and medical conditions.

Behavioral Health Program Components:

  • Care/Utilization Management:
    • Inpatient Management for inpatient, partial hospitalization, and residential treatment center (RTC) services.
    • Outpatient Management for members who have this component as part of their behavioral health benefit plan through BCBSTX. It includes management of intensive and some routine outpatient services.
  • Case Management Programs:
    • Intensive Case Management for members experiencing a high severity of symptoms by providing more intensive levels of intervention.
    • Condition Case Management for chronic BH conditions such as:
      • Depression
      • Alcohol and Substance Abuse Disorders
      • Anxiety and Panic Disorders
      • Bipolar Disorders
      • Eating Disorders
      • Schizophrenia and other Psychotic Disorders
      • Attention Deficit and Hyperactivity Disorder (ADD/ADHD)
    • Active Specialty Management for members who do not meet the criteria for Intensive or Condition Case Management but who have behavioral health needs and could benefit from extra support or services.
    • Care Coordination Early Intervention® (CCEI) Program provides outreach to higher risk members who often have complex psychosocial needs impacting their discharge plan.
    • Patient Safety Program(PSP) provides outreach calls to members that may have the potential of becoming higher risk for readmission(s) and/or frequent Emergency Room visits. The goal to provide resources and/or access to the treatment they need.
  • Specialty Programs:
    • Eating Disorder Specialty Team is a clinical team with expertise in the treatment of eating disorders who partners with eating disorder experts, treatment facilities as well as internal algorithms to identify and refer members to appropriate programs.
    • Autism Response Team whose focus is to provide expertise and support to families in planning the best course of Autism Spectrum Disorder (ASD) treatment for their family, including how to maximize their covered benefits.
  • Referrals to other medical management programs, and wellness and prevention campaigns

Members are responsible for requesting prior authorization before treatment, when prior authorization is required. Behavioral health professionals and physicians or a member’s family member may request prior authorization on behalf of the member. BCBSTX will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary.

 

Inpatient and Alternative Levels of Care

Prior authorization is required for all inpatient, residential treatment center (RTC) and partial hospitalization admissions.

  • Elective or non-emergency hospital admissions must be authorized prior to admission or within two business days of an emergency admission.
  • To determine eligibility and benefit coverage prior to service and to determine if RTC services are covered by a specific employer group, members or behavioral health professionals and physicians may call the Behavioral Health number that is listed on the back of the member’s ID card.

Outpatient Services

The intensive outpatient services requires authorization prior to initiation of service to determine that the services are medically necessary, clinically appropriate and contribute to the successful outcome of treatment.

  • Intensive Outpatient Programs (IOP)
  • Applied Behavior Analysis(ABA)
  • Outpatient Electroconvulsive therapy (ECT)
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Psychological testing and neuropsychological testing in some cases; BCBSTX would notify the provider if prior authorization is required for these testing services.

This requirement applies only for members who have BH Outpatient Management as part of their BH benefit plan through BCBSTX.

Federal Employee Program® (FEP®) members are managed by BCBSTX. FEP members must request prior authorization for Applied Behavior Analysis (ABA), Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rMTS) services. They are not required to request prior authorization for any other outpatient behavioral health services including Partial Hospitalization Programs.


Members are responsible for requesting prior authorization when authorization is required, although behavioral health professionals, physicians or member's family member may request prior authorization on behalf of the member. BCBSTX will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary.

 

Inpatient and Alternative Levels of Care

Outpatient Services:

  • For the services listed above that may require prior authorization, providers can request online using Availity Authorization & Referrals or members and providers can call the behavioral health number on the back of their ID card.
  • Behavioral health providers, physicians or a member’s family member may request prior authorization on behalf of the member.
  • Prior authorization for outpatient services requires completion of forms located under Education and Reference/Forms on the provider website.
  • Prior authorization requirements for ABA services are outlined in the “Behavioral Health Outpatient Management Program” section located in the Related Resources section under Clinical Resources/Behavioral Health on the provider website.

Inpatient and Alternative Levels of Care

Members who do not request prior authorization for inpatient and alternative levels of care behavioral health treatment may experience the same benefit reductions that apply to medical services. Medically unnecessary claims will not be reimbursed.

 

Outpatient

If a member receives any of the outpatient behavioral health services listed below without prior authorization, BCBSTX will request clinical information from the provider for a medical necessity review. The member will also receive notification.

  • Intensive Outpatient Program (IOP)
  • Applied Behavior Analysis (ABA)
  • Outpatient Electroconvulsive therapy (ECT)
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Psychological testing and neuropsychological testing in some cases; BCBSTX would notify the provider if prior authorization is required for these testing services.

Behavioral Health Appointment Access Standards

Behavioral Health providers have contractually agreed to offer appointments to our members according to the following appointment access standards:

 

Initial Visit for Routine Care: Within 10 working days
Follow-up for Routine Care: Within 30 calendar days
Urgent: Within 24 hours
Non-life threatening emergency: Within six (6) hours
Life threatening/emergency: Within one (1) hour

 

BCBSTX is accountable for performance on national measures, like the Health Effectiveness Data Information Sets (HEDIS). Several of these measures specify expected timeframes for appointments with a behavioral health professional.

  • Expectation that member has a follow up appointment with a behavioral health professional following a mental health inpatient admission within 7 and 30 days
  • For members treated with Antidepressant medication
    • Continuation of care for 12 weeks of continuous treatment (during Acute phase)
    • Continuation of care for 180 days (Continuation phase)
  • For children (6-12 years old) who are prescribed ADHD medication
    • One follow up visit the first 30 days after medication dispensed (Initiation phase)
    • At least two (2) visits with provider in the first 270 days after Initiation phase ends (Continuation and Maintenance phase)
  • For members treated with a new diagnosis of alcohol or drug dependence
    • Treatment initiation through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization program within 14 days following the diagnosis (initiation phase)
    • At least 2 visits/services, in addition to the treatment initiation encounter, within 30 days of initial diagnosis (encounter phase)

Updates about the Behavioral Health program will be communicated in the News and Updates and Clinical Resources sections on bcbstx.com/provider and in Blue Review.


Behavioral Health Insourcing Orientation


Prior Authorization Managed by BCBSTX:

  • Use Availity Authorization & Referrals tool
  • Call 1-800-528-7264 or the number listed on the back of the member ID card.

  • Submit completed Behavioral Health Forms to:
    Blue Cross and Blue Shield of Texas Behavioral Health Unit
    PO Box 660241
    Dallas, TX 75266-0241
    Fax Number: toll-free 877-361-7646

Prior Authorization Managed by Magellan:

  • Call 1-800-729-2422 or the number on the back of the member ID card.

Other Contact Information:

  • For eligibility and benefits, contact Availity or other electronic vendor or call 1-800-451-0287, 8 a.m. to 8 p.m. CT, M-F.
  • For claim status, contact Availity or other electronic vendor.
  • For claim adjustments, submit a a Claim Review Form PDF Document or call 1-800-451-0287, 8 a.m. to 8 p.m CT, M-F
  • For contract questions, contact your Network Management office